CONTINUOUS BLOOD PRESSURE TRACINGS IN MAN:

AN APPARATUS’

A. C. KOLLS

From the Pharmacological Laboratories of the Johns Hopkins University and

Washington University, School of Medicine, St. Louis

Received for publication May 4 1920

The method of Mosso (1) is undoubtedly the first attempt

to obtain continuous blood pressure records in man. Using,
as it does, the digital arteries of two fingers of each hand, the
tracings obtained are not only those of arterial pressure, but
volume of the parts and also changes in the arterioles of the
fingers which may occur quite independent of the general vascular
reaction. H#{252}rthle (2), in the year following Mosso’s publica-
tion, devised a plethysmographic method for the arm which has
seen very little use, principally because of the cumbersome
apparatus and the discomfort to the subject. Erlanger (3)
devised a practical method for the observation of the pressure
with which one can determine with great accuracy whether the
pressure rises or falls. The method does not, however, give a
direct insight into the size of the variation, since it is only the
change in the size and character of the sphygmograph tracing
obtained with a cuff inflated to certain pressure and maintained
at that level. Groedel (4) some years later used the Erlanger
method with the Uskoff sphygmomanometer. Recently, Fantus

1 This investigation was begun in 1915 at the University of Wisconsin. A

valve was constructed at that institution, but the major portion of the work was
done at the Johns Hopkins University. The apparatus was demonstrated before
the Johns Hopkins Hospital Medical Society, January, 1917, and is abstracted
in the Johns Hopkins Hospital Bulletin, xxviii, 212, 1917. Due, however, to the
war and other unavoidable circumstances completion of the problem and publi-
cation were postponed. The apparatus was recently described and demonstrated
before the joint session of the Federation of American Societies for Experimental
Biology, Cincinnati, Ohio, December, 1919.

433
434 A. C. KOLLS

(5) described a method by which rapid repeated observations

may be obtained with the Erlanger sphygmomanometer. The
method is not continuous, yet it affords a means of studying
rapid changes in pressure. The rapidity with which the obser-
vations may be made is limited by the time necessary for inflation
and deflation, and the latter must, of necessity, be rather slow
in order to include the respiratory oscillation.
A diligent search through the literature has failed to reveal
any description of an indirect method which will give a continuous
tracing of human pressure without the objections just cited.
That a continuous method would have a decided advantage over
instantaneous determinations and ought to prove of value in
the study of many reactions such as drug reactions and the influ-
ence of the emotions, is apparent.
The method to be described differs from those just cited in
that the tracing is the manometric pressure necessary to main-
tain the artery at the point of collapse. This is accomplished
automatically by means of an electromagnetic valve which allows
air to flow into the bag within the compression cuff when the
pressure in it is below the intra-arterial pressure and, on the other
hand, allows air to escape when the intra-arterial pressure falls
below that in the cuff. The criterion for systolic pressure is
a well recognized one; namely, the use of a sphygmograph distal
to the compression cuff.
The type of sphygmograph employed, is a modification of
one described by Erlanger (6). It is connected to a small cuff
which is placed below the compression cuff. The sphygmograph
will be described later.
Figure 1 is a schematic representation of the apparatus while
figure 2 is a photographic reproduction. A and B in figure 1
are the upper and lower cuffs respectively. They measure 11
and 5 cm. and the rubber bags within are 10 and 4 cm. wide.
The bags are connected through the stopcock C. B is also con-
nected with the bulb of the sphygmoscope, D. E is the electro-
magnetic valve which supplies air for the obliteration of the
artery when pulsations escape beneath the upper cuff and on the
other hand allows air to escape from the system when pulsations
 CONTINUOUS BLOOD PRESSURE TRACINGS IN MAN 435

do not escape. The source of pressure is a large glass bottle F

in which a pressure is maintained by means of the bulb G which
is pumped at intervals. This pressure is kept considerably
above the blood pressure of the subject, 40 or more mm., usually.
The sphygmograph. Above the sphygmoscope (D) in figure 1
is seen the modified sphygmograph. It is an inverted piston
recorder, whose barrel is attached to a counterbalanced metal
lever. The immovable piston is made of brass and is highly
polished. The movable portion can be made of metal. It has

FIG. 1. DIAGRAM OF THE APPARATUS

been found, however, that hard rubber or Bakelite, due to the

lightness of the material, increases the delicacy of the instrument.
The electrical contact on the lever is a small piece of platinum
wire, which rests on an adjustable screw whose top is coated with
a thin layer of mercury.
Although a disk of platinum can be used for this contact, it
has the disadvantage that any vibration of the apparatus or
the table supporting it is sufficient to break the contact, and
interfere with operation of the apparatus. Early experiments
436 A. C. KOLLS

were carried out with an ordinary piston recorder; the only ob-
jection found was the tendency for the collection of dust on the
piston, which interfered with the free movement of the instrument.

FIG. 2

The two contacts of the sphygmograph are shown in the dia-

gram as closing the relay circuit. The current used for this
circuit is very small, a nearly exhausted dry cell is quite sufficient.
A most important feature is a large capacity condenser which
is placed across the relay circuit. A telephone condenser with
 CONTINUOUS BLOOD PRESSURE TRACINGS IN MAN 437

a capacity of two microfarads is capable of eliminating the spark

at the contacts on the sphygmograph. If sparking occurs here
the contacts soon become dirty and lever is raised with difficulty
and the crest of the pulse wave is lost. The recorded pressure
is then considerably below the true systolic pressure.

.--------Y

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FIG. 3. ELECTROMAGNETIC vALvE-AcTUAL SIZE

The valve. Figure 3 shows the construction of the valve.

The portion below the dotted line X-Y is shown in section.

The air reservoir is connected at 0 while P and Q both connect

with the manometer and compression cuff. The poles of the
electromagnet protrude into the chamber containing the soft
iron armature M. Other iron parts are indicated by the wide
438 A. c. KOLLS

cross lines, the remainder of the valve is made of brass. Attached

to the armature is a shaft with small conical valves at either end.
A coil spring R retains the armature in the position indicated in
the drawing, which is the position in which air slowly escapes
from the compression system through the hole S by way of the
needle valve T. When the electromagnets are actuated, that
is, when the lever of the sphygmograph is raised breaking the
relay circuit, the escape of air from the system is suspended and
more air flows into the system from the reservoir. Thus air
is always escaping from the system except when pulsations strike
the lower cuff. The amount of air which flows into the system
with each pulsation can be regulated by means of the adjust-
ment H, figure 1.
Observations are made in the following manner. The two
cuffs are adjusted to the subject’s upper arm. Pressure in the
reservoir is raised considerably above the anticipated level of
the blood pressure. Communication between the cuffs is estab-
lished through the stopcock which connects them. The vent
(I) between the sphygmoscope and sphygmograph is opened.
The circuit to the valve is closed, the relay circuit being open
the valve is thus opened, and the pressure gradually mounts in
both the sphygmograph system and the compression system.
When the pressure of the manometer is approximately 90 or
100 mm. the stopcock between the cuffs is closed. The pressure
is allowed to rise until the subject no longer feels the pulsation
under the cuff. The vent on the sphygmoscope is then closed
and the relay circuit is closed. The manometric pressure rapidly
falls to the level at which pulsations escape the compression
cuff. The drum is then started. With every pulsation that
strikes the lower cuff a small amount of air flows into the upper
cuff and the manometer rises. When pulsations do not escape
beneath the upper cuff the manometer falls owing to the escape
of air from the valve.
Figures 4 and 5 are short typical tracings obtained with this
apparatus. The duration of the observation can be extended
to fifteen or twenty minutes. Considerable discomfort is experi-
enced if the time is extended any farther. Inflation and defla-
CONTINUOUS BLOOD PRESSURE TRACINGS IN MAN 439

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440 A. C. KOLLS

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CONTINUOUS BLOOD PRESSURE TRACINGS IN MAN 441

tion are carried out with such ease that ordinarily the author has
adopted the plan of taking a tracing for four or five minutes,
then deflating and resting the subject’s arm for about a minute
and resuming the tracing. No ill effects have been seen following
the use of the apparatus.
The tracing obtained is not true systolic pressure at all points.
Since the amount of air which flows into the cuff with a single
oscillation of the sphygmograph is limited, the true height of
very rapid changes is not attained by the manometer. It may
be contended by some that the width of the compression cuff
introduces an error. This is of no moment in studying changes
which are entirely relative. Furthermore, no very appreciable
difference has been demonstrated between the cuff described in
this apparatus and cuffs of 16 cm. or more in width. Control
experiments have been made by means of instantaneous determi-
nations on the other arm. These have been entirely satisfactory,
differing only a few millimeters from the pressures as measured
on the tracing. The subjective sensation which one observes
when pulsations begin to pass under a compression cuff can
always be used in testing the operation of the apparatus, either
by questioning the subject or by placing the cuffs upon one’s
own arm.
SUMMARY

An apparatus is described with which continuous blood pres-

sure records can be obtained in man. It is comparatively
simple in design, necessitating only an electromagnetic valve
in addition to ordinary laboratory equipment. Typical tracings
obtained with the apparatus are shown and its application to
various problems is indicated.

REFERENCES

(1) Mosso: Arch. Ital. de Biol., 1895, xxiii, 177.

(2) HURTHLE: Deut. Med. Wochenschr., 1896, p. 574.
(3) ERLANGER: Jour. Exp. Med., 1905, vii, 676.
(4) GROEDEL: Zeitschr. f. Kim. Med., 1910, lxx, 47.
(5) FANTUS: Jour. Amer. Med. Ass., 1917, lcviii, 1807.
(6) ERLANGER: Johns Hopkins Hosp. Rep., 1904, xii, 53.